Evaluation of the transurethral ethanol ablation of the prostate (TEAP) for symptomatic benign prostatic hyperplasia (BPH): a European multi-center evaluation.

OBJECTIVE: We prospectively conducted a European multi-center study to assess the safety and efficacy of injecting dehydrated ethanol using a specialized injection system for the treatment of BPH. METHODS: Patients with symptomatic BPH were enrolled and evaluated to undergo transurethral ethanol ablation of the prostate for their BPH condition. Procedures were performed using the ProstaJect device. Treatment dosages were based on prostate volume, prostatic urethral length and median lobe involvement. Follow-up evaluations were done at four days and one, three, six and 12 months. RESULTS: One-hundred fifteen symptomatic patients underwent the transurethral ethanol ablation procedure and ninety-four patients have been followed and evaluated for the entire 12-month post-treatment period. The average prostate volume was 45.9 g, and average ethanol injected was 14 ml. Post-operatively, 98% of patients voided spontaneously four days following treatment. Significant reduction in reported lower urinary tract symptoms was evidenced at the one-month follow-up visit and maintained through 12 months follow-up, with International Prostate Symptom (IPSS) and Quality of Life (QoL) scores decreased by more than 50%. Peak flow rates (Q(max)) improved by 35% by the three-month evaluation and these results were sustained through to 12-months follow-up. The average prostate volume reduction was 16%. Adverse events included discomfort or irritative voiding symptoms in 26% of patients, hematuria in 16%, with retrograde ejaculation, and erectile dysfunction reported in less than 3% of patients. The majority of these events required no intervention. Two patients experienced serious adverse events (bladder necrosis) and underwent open surgery that included a urinary diversion and a ureteral implantataion. During the one year follow- up, 7% of patients required a trans-urethral resection of prostate (TURP). CONCLUSIONS: This preliminary multi-center data, representing the largest reported cohort to date, suggests that TEAP may be considered an effective minimally invasive treatment option for lower urinary tract symptoms secondary to BPH. Analyses of safety lead to a procedure modification for needle placement more distal from the bladder neck. Objective reduction in symptoms was not correlated in prostate volume reduction suggesting a non-purely mechanical effect.

Diagnosis and therapy of the female urethral diverticula.

The various diagnostic and therapeutic modalities currently in use for urethral diverticula are reviewed. Various radiographic techniques have been reported, but only voiding cystourethrography (VCUG) and positive-pressure urethrography (PPU) are currently utilized. Urethroscopy is another suitable technique for diagnosis. Various sonographic techniques have been proposed, but their sensitivity is improved only by the transvaginal approach and magnetic resonance imaging (MRI). Various treatment methods have been proposed. The standard operative approach is surgical, through the vagina. The techniques currently in use to treat urethral diverticula are the Spence procedure, the typical urethral diverticulectomy, and the Tancer partial ablation technique. A full history, and physical examination is the first step in screening. When the diagnosis is suspected ultrasound and radiological imaging is necessary. Sonography is the first non-invasive examination to be performed. In negative cases it is imperative to perform a PPU or MRI. Symptomatic and very large diverticula must be treated in the easiest way possible. The best treatment, except for complicated and infected diverticula, is excision.

Influence of pasture sward height and concentrate supplementation on intake, digestibility, and grazing time of lactating beef cows.

To establish the effect of sward height (SH) and concentrate supplementation on performance of grazing cattle, 24 crossbred Angus beef cows (535 kg BW) and calves (114 kg BW) were grouped by weight and calving date. They were randomly assigned to two SH treatments, either 4 to 8 cm or 8 to 11 cm, and fed three levels of supplement, high, low, or none, consisting of 6.24, 3.12, and 0 kg x animal(-1) x d(-1), respectively. The experiment was repeated over three 15-d periods in 1996: May (P1), June/July (P2), and August (P3). No SH x supplement level x period or SH x supplement level interactions (P > 0.10) were evident for responses tested. Cows on lower SH had greater (P < 0.08) DMI but spent an additional 1.3 h/d (P < 0.01) grazing compared with cows on higher SH. Sward height had no influence (P > 0.10) on forage DM digestibility (DMD). Forage DMI, DMD, and grazing time (GT) decreased (P < 0.05) as supplementation increased. Nonetheless, supplemented cows consumed more total DMI (P < 0.08) than unsupplemented cows. Cows consumed 2.4 kg/d more forage DM (P < 0.01) in P1 and P2 than in P3. Cows grazed 1.3 h/d (P < 0.01) less in P1 than in P2 and P3. Grazing efficiency (DMI/h GT) declined as supplementation increased and grazing season advanced to P3 (P < 0.01). Decreased forage DMI and grazing efficiency with increasing supplementation suggests that supplemented cattle should be able to maintain productivity while grazing at SH lower than unsupplemented cattle.

Extracorporeal shock wave lithotripsy in ureteral and kidney malformations.

INTRODUCTION: Extracorporeal shock wave lithotripsy (SWL) has long been accepted worldwide in the treatment of kidney stone disease. Upper ureter calculi in ureteral and kidney malformations are rather frequent (10-25%). The aims of this retrospective study were to determine whether malformations might impair fragment expulsion. MATERIAL AND METHODS: From 1986 to 1995, 203 patients with ureteral and kidney malformations were treated and followed up for a minimum of 1 year to a maximum of 9 years. Malformations included: ureteropelvic junction stenosis, horseshoe kidney, renal malrotation, renal ectopia, duplicated ureter, nonobstructive megaureter, medullary sponge kidney and caliceal diverticula. As pretreatment workup, all patients underwent conventional studies prior to SWL treatment: X-rays, renal ultrasound, intravenous pyelography, routine blood tests and urinalysis. All examinations were repeated at regular intervals for the first 6 months. Patients with metabolic disorders were excluded from the study. We also excluded patients with a follow-up of under 1 year. We considered three groups of patients: (1) stone-free patients at plain X-rays and ultrasound; (2) >90% elimination, i.e. stone-free patients at plain X-rays and positive at ultrasound; (3) patients with residual fragments at plain X-rays and ultrasound. RESULTS: 96 (55%) patients were in group 1 (stone free), 40 (19%) were in group 2 (>90% elimination) and 67 (26%) were in group 3 (residual). Residual stones were more frequent in patients with medullary sponge kidney (82%). In patients with renal ectopia the residual stone rate accounted for only 13% of cases. CONCLUSIONS: There is evidence that SWL should always be offered to patients with ureteral and kidney malformations. These patients should however be considered at high risk for recurrences and so they need to be carefully followed up.

Enhancement in the histological diagnosis of leprosy in patients with only sensory loss by demonstration of mycobacterial antigens using anti-BCG polyclonal antibodies.

This study was undertaken to assess whether the immunoperoxidase technique using anti-BCG serum is able to confirm the diagnosis of early leprosy among patients whose unique clinical manifestation is a localized area of sensory loss, in a higher proportion than the routine mycobacterial staining methods, namely hematoxylin-eosin and Wade. The study was held in the north of a hyper-endemic area of leprosy, Manaus, Amazonas (Brazil). Fifty-one paraffin-embedded skin biopsy blocks were retrieved and processed for the immunohistochemical study, by means of anti-BCG polyclonal antibodies for the detection of mycobacterial antigens. The routine stains confirmed the leprosy diagnosis in 17% of the cases, while the immunostaining method confirmed it in 47%. The McNemar test showed that the observed difference between these two techniques was statistically significant (p = < 0.05). In the same way, 50 blocks of skin conditions considered in the differential histopathological diagnosis of early leprosy were processed for the immunohistochemical test to analyze the possibility of false-positive results which occurred in 8 (16%) patients. The study suggests that immunostaining may increase the proportion of the routine histological diagnosis of leprosy in patients who have sensory loss only, even while using biopsies obtained in fieldwork conditions. This is very advantageous in hyper-endemic areas and in areas that are in the post-elimination period of leprosy control where sensory loss may be a sentinel sign of the disease.

Treatment of vaginal vault prolapse with abdominal sacral colpopexy using prolene mesh.

BACKGROUND: We report our experience on abdominal sacral colpopexy (CSP) with a prolene mesh in women with vaginal vault prolapse. METHODS: From 1994 to 1997 15 patients (average 57 years), underwent CSP. All patients suffered from a serious vaginal vault prolapse. Eight of them also had a uterine prolapse. Seven patients had already been operated for hysterectomy (5 vaginal, 2 abdominal). Four of them had already been operated for urinary incontinence: (3 Raz, 1 Burch). In 6 cases we have a colposuspension according to Burch associated with CSP. Average follow-up was 15 months. RESULTS: All the patients have carried a bladder catheter for 4-12 days (average 5 days). The patients who were sexually active have begun having normal sexual intercourse again. Neither relapses of the treated prolapses, no infections or rejections of the prosthesis have been verified. In 1 patient pollakiuria insensitive to anticholinergics has persisted. Four patients have complained of hypogastric "sense of weight", without any clinical evidence of pathology. CONCLUSION: Our survey confirms the information and the good result of this technique in the treatment of the total vaginal dome prolapse, also in comparison with our operations for sacrospinosous ligament fixation. This kind of treatment through the vagina, is not always possible, above all after hysterectomy with a very short vagina.

Evaluation and management of malfunctionings following implantation of the artificial urinary sphincter.

The authors report their experience of mechanical malfunctionings after placement of the AMS 800 artificial urinary sphincter. The aim of the study was to suggest outlines for the evaluation and management of these complications. From 1991 to 1998, 42 patients (39 men, 3 women with a mean age of 67.5 years) underwent artificial sphincter implantation of whom 5 patients required explantation of the prosthesis because of infection. The following mechanical malfunctionings occurred: 2 cases of air bubbles; 3 cases of pump overturning with tube kinking; 16 cases of persistent or recurrent incontinence 6-61 months postoperatively; and 1 case of cuff opened during sexual intercourse. Surgical revision of the prosthetic components was performed in the patients who presented mechanical malfunctionings. Several complications can arise after artificial sphincter placement (infection, urethral erosion, mechanical malfunction). In the last case, the authors stress the importance of an accurate diagnosis for the choice of exact treatment.

Abdominal sacral colpopexy with prolene mesh.

The objective was to evaluate abdominal colposacropexy using Prolene mesh to correct total vaginal vault prolapse or total procidentia. Between 1994 and 1997 we performed colposacropexy on 15 patients for simple vaginal vault prolapse (in 7 cases after hysterectomy) and for total uterine prolapse in 8 cases. In these cases a simple abdominal hysterectomy was performed. We simultaneously performed colposacropexy with colposuspension according to the Burch technique for urinary stress incontinence in 6 cases. The colposacropexy technique consisted of isolating the vaginal apex and creating a retroperitoneal tunnel from the vagina to the sacral promontory. Between the vaginal cul de sac and the sacrum, a mesh of Prolene is inserted and fixed with non-absorbable sutures. The Foley catheter was removed after 4-12 days (average 5). Average follow-up was 15 months. No intraoperative complications occurred, and all patients who were sexually active have resumed normal sexual activity; no infections or rejections of the prostheses have been verified. We believe that it is very important to restore the normal anatomic support of the vaginal vault after prolapse. This strong support is assured by fixing the vaginal apex to the periosteum of the sacrum using Prolene mesh. Colposacropexy with Prolene mesh is a safe and effective technique for the surgical therapy of vaginal vault prolapse.

Influence of mass and volume of ruminal contents on voluntary intake and digesta passage of a forage diet in steers.

To assess the influence of volume and mass of ruminal contents on voluntary intake and related variables, five ruminally cannulated steers (550 kg) were fed a low-quality forage diet (43.1% ADF, 8.1% CP) in a 5 x 5 Latin square experiment. Mass and volume of ruminal contents were altered by adding varying numbers and weights of filled tennis balls (6.7-cm diameter) to the rumen immediately before the initiation of each experimental period. Treatments consisted of 0 balls (control), 50 balls with a 1.1 specific gravity (SG), 100 balls with a 1.1 SG, 50 balls with a 1.3 SG, and 100 balls with a SG of 1.3. The total volume of balls was 7.25 and 14.5 L for 50 and 100 balls, respectively. The total weight of balls was 8.5 and 17 kg for 50 and 100 balls with a 1.1 SG and 10.75 and 21.5 kg for 50 and 100 balls with a 1.3 SG, respectively. Daily DMI was 8.3, 7.3, 7.0, 6.5, and 6.0 kg for control; 50, 1.1 SG; 50, 1.3 SG; 100, 1.1 SG; and 100, 1.3 SG, respectively. Addition of balls to the rumen reduced (P < .01) DMI. Increasing the number (P < .01) and SG (P <. 01) of the balls decreased DMI further. However, digestibilities of DM, NDF, ADF, and CP were not influenced by treatment. Increasing the number of balls in the rumen increased (P < .05) rate of passage of digesta from the rumen, but increasing SG of the balls did not alter rate of passage. There was a treatment x hour interaction (P < .05) in the proportion of ruminal digesta with a functional specific gravity (FSG) less than 1.1, which decreased with time after feeding for the control but increased with time after feeding for other treatments. Ruminal passage rate of inert particles added in the rumen of different SG (1.1 and 1.3) and length (1 and 3 mm) decreased (P < .05) as SG of the balls increased. Mean fecal particle size was greater for those treatments with the heavier balls. Both the number and SG of balls (P < .10) influenced total VFA, and total concentrations were greater for the control and for the 1.1 SG than for the 1.3 SG treatments.

Treatment of BPH with transurethral electrovaporization of the prostate (TUVP) using vaportrode VE-B. Two years follow-up.

The Authors report their experience on trasurethral vaporization of the prostate with Vaportrode for the treatment of BPH. In January 1996 we treated 24 patients suffering from cervico-urethral obstruction caused by BPH with electrovaporization of the prostate using a cutting current of between 180 and 250 Watts (average 200 Watts). Exclusion criteria was: PSA > 3 ng/ml. The catheter was removed after 24 hours. Follow-up of all patients is 27 months. 23 patients were evaluated. Results at follow-up were: mean maximum flow (Qmax) 9.31 ml/sec preoperative was 19.5 ml/sec after 6 months, 18.3 after 12 months and 18.0 after 24 months; mean symptom score decreased from 18.1 to 10.4 after 6 months, to 3.2 after 12 months and to 4.8 after 24 months; QL index decreased from 4.6 to 2.3 at 6 months, to 1.4 after 12 months and 24 months; the average voiding pressure decreased from 62.8 cm/H20 to 23.2 cm/H20 after 6 months, to 21.2 after 12 months and to 23.8 after 24 months. There was no post voiding residual urine 2 days after treatment in all patients. Follow-up shows transurethral electrovaporization of the prostate is an efficient and safe technique for treatment of BPH.

[Intestinal anastomosis in urology: comparison of methods]. / Anastomosi intestinali in urologia: tecniche a confronto.

BACKGROUND: Three different intestinal anastomosis were compared during reconstructive urologic surgery; we evaluated time, cost and incidence of complications. MATERIALS AND METHODS: From November 1993 to February 1997, 45 patients (43 males and 2 females) were carried out ileal resection to fashion 30 ileal neobladder, 8 ileal conduit and 7 augmentation ileocystoplasty. The patients were randomized in 3 groups; in the first the intestinal continuity was performed by B.A.R.; the second one was treated by GLA stapling device; the last underwent a manual suture with interrupted stiches double layer (vicryl). RESULTS: The mean follow-up was 18 months. The mean time of canalization was 6.3 days. The complications were: one intestinal subocclusion (group 1); one abdominal wound infection (group 2); one anastomotic leak and one pulmonary embolism (group 3). The mean time of anastomosis was 18, 12 and 39 minutes respectively. The average total cost was 915,000 lire in the group 1; 1,280,000 lire in the group 2; 632,000 lire in the group 3. CONCLUSIONS: We believe that Biofragmentable. Anastomosis Ring (B.A.R.) is more convenient and advisable in reconstructive urologic surgery, for their quickness, effectiveness and final total cost.

Minimally invasive treatment of BPH with interstitial diode laser coagulation.

The Authors report their preliminary experience on the use of interstitial laser coagulation (ILC) for the treatment of benign prostatic hyperplasia (BPH). Twenty-three patients underwent interstitial laser treatment of BPH with the Indigo 830 laser system, from April 1996 to September 1997. Inclusion criteria were: maximum flow rate < 12 ml/sec, postvoiding residual volume < 300 ml, AUA symptom score > 13. All patients were catheterized for 10 days postreatment. Average follow up was 10.9 months. Marked improvement was shown at one, three and six months in terms of AUA score, maximum urinary flow rates, QL index, postvoiding residual volume, voiding bladder pressure values and prostatic weight reduction. No major complication were reported. The Authors believe that ILC is an easy and effective treatment for elder and compromised patients with lower urinary tract symptoms due to BPH.

[Intestinal anastomosis in urology. Comparison of techniques]. / Anastomosi intestinali in urologia. Tecniche a confronto.

BACKGROUND: Three different intestinal anastomosis were compared during reconstructive urologic surgery; time, cost and incidence of complications were evaluated. METHODS: From November 1993 to February 1997, 45 patients (43 males and 2 females) were submitted to ileal resection to fashion 30 ileal neobladder, 8 ileal conduits and 7 augmentation ileocystoplasties. The patients were randomized in 3 groups. In the first group the intestinal continuity was performed by BAR; the second one was treated by GIA stapling device; the last underwent a manual suture with interrupted stitches double layer (vicryl). RESULTS: The mean follow-up was 18 months. The mean time of canalization was 6.3 days. The complications were: one intestinal subocclusion (group 1); one abdominal wound infection (group 2); one anastomotic leak and one pulmonary embolism (group 3). The mean time of anastomosis was 18, 12 and 39 minutes respectively. The average total cost was 915,000 lire in group 1; 1,280,000 lire in group 2; 632,000 lire in group 3. CONCLUSIONS: The conclusion is drawn that mechanical devices (BAR and stapler) are more convenient and advisable in reconstructive urologic surgery, for their quickness, effectiveness and final total cost.

Treatment of benign prostatic hyperplasia with transurethral electrovaporization of the prostate (TUVP) using Vaportrode VE-B. Two years follow-up.

BACKGROUND: The authors report their experience on transurethral vaporization of the prostate with Vaportode for the treatment of BPH. METHODS: In January 1996 we treated 24 patients suffering from cervico-urethral obstruction caused by BPH with electrovaporization of the prostate using a cutting current of between 180 and 250 Watts (average 200 Watts). Exclusion criteria was: PSA > 3 ng/ml. The catheter was removed after 24 hours. Follow-up of all patients is 27 months. Twenty-three patients were evaluated. RESULTS: Results at follow-up were; mean maximum flow (Qmax) 9.31 ml/sec preoperative was 19.5 ml/sec after 6 months, 18.3 after 12 months and 18.0 after 24 months; mean symptom score decreased from 18.1 to 10.4 after 6 months, to 3.2 after 12 months and to 4.8 after 24 months; QL index decreased from 4.6 to 2.3 at 6 months, to 1.4 after 12 months and 24 months; the average avoiding pressure decreased from 62.8 cm/H2O to 23.2 cm/H2O after 6 months, to 21.2 after 12 months and to 23.8 after 24 months. There was no post voiding residual urine 2 days after treatment in all patients. CONCLUSIONS: Follow-up shows transurethral electrovaporization of the prostate is an efficient and safe technique for treatment of BPH.

Treatment of urinary incontinence with AMS 800 artificial urinary sphincter.

BACKGROUND: Urinary incontinence has a significant impact on the quality of life for patients. The introduction of the AMS 800 artificial urinary sphincter by American Medical Systems (Minnetonka, MN, USA) has revolutionized the treatment of urinary incontinence due to pure sphincteric incompetence. PATIENTS AND METHODS: From April 1989 to October 1997, a total of 52 patients (42 men and 3 women) underwent implantation of the AMS 800 artificial sphincter. Patient age ranged from 31 to 87 years (mean 69.5 years). They all were suffering from urinary incontinence caused by sphincteric damage, always of iatrogenic origin. Follow-up was 5-110 months, with a mean of 35 months. RESULTS: The restoration of continence was complete for 35 patients and allowed them all to return to their normal life. 7 of the patients who had a successful implant died because of other problems. For 2 patients follow-up was not available. Explantation was performed 8 times: in 5 male patients the device was removed because of periprosthetic infections; in 1 female patient with ileal neobladder, because of serious urethral necrosis; and in 2 male patients because of an urethral erosion. CONCLUSIONS: The AMS 800 artificial urinary sphincter is the most efficacious treatment currently available for urinary incontinence due to pure sphincteric incompetence. Implanted patients achieved acceptable urinary control. The implantation is associated with 2 distinct complications: surgical and mechanical.

Management of hemorrhage after percutaneous renal surgery.

Percutaneous renal surgery is routine therapy for a number of renal pathologies. It is a technique not without complications, often serious ones, of which the worst is bleeding. We reviewed our experience of the incidence, etiology, and management of this serious complication to determine a protocol of treatment that will minimize the consequences. Between 1984 and 1996, we carried out 976 percutaneous operations for reno-calix stones, pyeloureteral junction stenosis, neoplasia of the renal pelvis, diagnosis, and ureteral prostheses. In all cases, the percutaneous access was achieved through a lower calix in the posterior axillary line with the patient in a prone position. The lithotripsy was performed with ultrasound and balistic energy lithotripters. Antegrade endopyelotomy was performed according to our technique. At the end of the procedure, a nephrostomy tube was positioned, 24F for lithotripsy and 16F for endopyelotomy. The nephrostomy tube was removed after 24 to 48 hours. In this series, 146 patients (15%) presented significant perioperative bleeding. In 97 cases (10%), this complication was resolved with the repositioning of the nephrostomy tube, bedrest in a supine position, and observation, whereas in 49 cases (5%), clamping of the nephrostomy tube for 24 hours was necessary. In 56 patients (5.7%), two blood transfusions were necessary, and three patients (0.3%) had bleeding 10, 12, and 20 days after the operation, which was resolved by embolization of the lacerated vessel.

Diverticula of the female urethra.

OBJECTIVE: To determine the optimum procedure for the diagnosis and therapy of diveticula of the female urethra. PATIENTS AND METHODS: The study included 18 patients with urethral diverticula treated at the Cristo Re Hospital in Rome between 1987 and 1995. Most of the patients were suffering from cystitis (eight), dysuria (seven) and recurring urinary infections (11). Less frequently, more specific symptoms were present such as post-voiding dribbling (two) and anterior vaginal mass (three). The pre-operative evaluation included a history, physical examination, voiding and positive pressure voiding cysto-urethrography (VCUG) and urodynamic tests. A 'typical' surgical excision of the diverticula was carried out in all cases. Surgical excision was combined with cystopexis (Raz operation) in four patients with urinary stress incontinence and three with detrusor instability were treated postoperatively with anticholinergics for 3 months. The outcome was evaluated by a physical examination and urodynamic tests at 3, 6 and 12 months postoperatively; the mean (range) follow-up was 34 (2-80) months. RESULTS: All the urethral diverticula were in the distal two-thirds of the urethra, along the posterolateral wall. The VCUG was sufficient for diagnosis in eight patients while the other 10 required a positive-pressure VCUG. Fifteen patients were evaluated; complications included a urinary tract infection for 2 months in four patients and stress incontinence for 2 months in two. There were no recurrences or urethrovaginal fistulae. CONCLUSIONS: Diverticula in the female urethra are difficult to diagnose because the symptoms can be misleading; the positive-pressure VCUG is useful in doubtful cases. However, a detailed history and physical examination are mandatory.

Ureteral occlusion prosthesis.

Although temporary or definitive complete ureteral occlusion is rarely needed, there is a considerable number of reports introducing different devices to achieve this goal, most of which can be inserted with minimally invasive procedures. Easy placement is considered of paramount importance, as the candidates are very often in bad general condition as a result of previous surgery, radiotherapy, or other palliative treatments for cancer. A device that can be inserted and removed percutaneously is presented herein. It can be employed in cases of ureteral fistulas resulting from radiotherapy and ureterosigmoidostomy with good results. The technique is simple and not time consuming.